Residents in every U.S. county are expected to have at least one insurer to buy coverage from on Obamacare’s exchange when open enrollment starts in November, but several difficult decisions lie ahead for customers, particularly those who will not receive any help paying for their premiums.

Those customers are facing significantly higher costs for their policies, and those whose current insurer isn’t providing coverage for 2018, whether subsidized or not, likely will have to change doctors and hospitals to make sure they aren’t slammed with high out-of-pocket medical expenses.